Healthcare claim transactions, such as prescription claim requests, are often routed from a healthcare provider, such as a pharmacy or hospital, to a claims processor through a service provider system. Typically, when a healthcare transaction is received by the service provider system, the service provider system will perform one or more edits on the healthcare claim transaction. For example, edits that are specified by a healthcare provider chain, such as edits to ensure that the healthcare claim transaction is formatted properly and includes required information, may be performed. In certain circumstances, when a healthcare claim transaction is rejected as a result of an edit, the healthcare provider may wish to override the edit and, therefore, suppress the rejection.
There are several techniques that are utilized to override edits including a static override, a master override, and an algorithm based override. The first two techniques require the entry of a constant edit override code that may be known by an employee at the healthcare provider that is submitting the healthcare claim transaction. Because the first two techniques do not allow a healthcare provider to evaluate a reason for overriding the edit, many healthcare providers prefer an algorithm based override technique. With an algorithm based override, the employee typically contacts a help desk or call-in support center associated with the healthcare provider and explains the reasoning for the override. If the reasoning is sufficient, the employee is given an override code that is specific to the healthcare claim transaction, and the employee utilizes this override code to suppress the edit during a resubmission of the healthcare claim transaction. Although an algorithm based override technique allows a healthcare provider to evaluate override reasons, the implementation of a support center is undesirable because it often entails a relatively high expense and administrative cost. Additionally, the employee may incorrectly record a provided override code, thereby leading to additional administrative difficulties.
Therefore, a need exists for systems and methods for overriding rejections of healthcare claim transactions that are generated as a result of one or more edits performed on the healthcare claim transactions.